<%@ include file="/common/taglibs.jsp"%>

<head>
    <title><fmt:message key="wellness.title"/></title>
    <meta name="heading" content="<fmt:message key='wellness.heading'/>"/>
</head>

<body id="signup"/>

<div class="separator"></div>

<s:form name="wellnessProfileForm" action="savePwpWellness" method="post" validate="true">
    <li class="info">
        <fmt:message key="wellness.message"/>
    </li>

	<li>
        <div>
            <div class="left">
		    <s:datetimepicker displayFormat="dd/mm/yyyy" 
					key="pwp.recorddate" 
					startDate="01/01"
					name="pwprecorddate" 
					required="true" 
					cssClass="small"/>
            </div>
            <div>
		
			<s:radio key="pwp.framesize"
		             name="pwp.framesize"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3'}"
		             list="{'small','medium','large'}"             
		            />
            </div>
        </div>
    </li>
    

	<li>
        <div>
            <div class="left">
                <s:select key="pwp.height" 
                		name="pwp.height"
			             listKey ="{'1','2','3','4','5'}"
			             list="{'','','','',''}"             
                		theme="xhtml" 
                		required="true" 
                		cssClass="" />
            </div>
            <div>
                <s:select key="pwp.weight" 
                		name="pwp.weight"
			             listKey ="{'1','2','3','4','5'}"
            			 list="{'','','','',''}"             
                		theme="xhtml" 
                		required="true" 
                		cssClass="text " />
            </div>
        </div>
    </li>

	<li>
        <div>
            <div class="left">

		  	<s:select key="pwp.age" 
		      		name="pwp.age"
			        listKey ="{'1','2','3','4','5'}"
		    	    list="{'','','','',''}"             
		      		theme="xhtml" 
		      		required="true" 
		      		cssClass="medium" />
            </div>
            <div>
		
		    <s:radio key="pwp.socialactivity"
		             name="pwp.socialactivity"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'None','slightly','moderate','quite a bit','extremly'}"             
		            />
            </div>
        </div>
    </li>
    
    
	<li>
        <div>
            <div class="left">

		    <s:radio key="pwp.exercisedays"
		             name="pwp.exercisedays"
		             required="true"
		             cssClass="text"
		             listKey ="{'0','1','2','3','4','5','6','7'}"
		             list="{'None','one day','two days','three days','four days','five days','six days','seven days'}"             
		            />
            </div>
            <div>
		
		    <s:radio key="pwp.strengthexercise"
		             name="pwp.strengthexercise"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4'}"
		             list="{'none','once a week ','twice a week','three or more times a week'}"             
		            />
    
            </div>
        </div>
    </li>

	<li>
        <div>
            <div class="left">
		    <s:radio key="pwp.stretchingexercise"
		             name="pwp.stretchingexercise"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4'}"
		             list="{'none','once a week ','twice a week','three or more times a week'}"             
		            />
            </div>
            <div>
		    
		    <s:radio key="pwp.breakfast"
		             name="pwp.breakfast"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4'}"
		             list="{'every day','most mornings ','three or more times a week','seldom'}"             
		            />

            </div>
        </div>
    </li>
	<li>
        <div>
            <div class="left">

		    <s:radio key="pwp.chronicpain"
		             name="pwp.chronicpain"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5','6'}"
		             list="{'none','very mild ','mild','moderate','severe','very severe'}"             
		            />
            </div>
            <div>
		
		    <s:radio key="pwp.healthlimitations"
		             name="pwp.healthlimitations"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'none','a little ','some','quite a bit','could not do daily work'}"             
		            />

            </div>
        </div>
    </li>
	<li>
        <div>
            <div class="left">

		    <s:radio key="pwp.emotionalproblems"
		             name="pwp.emotionalproblems"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
		    
            </div>
            <div>
		    
		    <s:radio key="pwp.snacking"
		             name="pwp.snacking"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
            </div>
        </div>
    </li>
    
	<li>
        <div>
            <div class="left">

		    <s:radio key="pwp.salt"
		             name="pwp.salt"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
            </div>
            <div>
		    
		    <s:radio key="pwp.lifting"
		             name="pwp.lifting"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
    
            </div>
        </div>
    </li>
	<li>
        <div>
            <div class="left">

		    <s:radio key="pwp.drinkinganddriving"
		             name="pwp.drinkinganddriving"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
            </div>
            <div>
		    
		    <s:radio key="pwp.physicalexam"
		             name="pwp.physicalexam"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
            </div>
        </div>
    </li>
    

      <li>
        <div>
            <div class="left">
                <fmt:message key="q39.womenshealthissues"/>
                <s:checkbox key="pwp.womenpregnant" name="pwp.womenpregnant" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="pwp.exampap" name="pwp.exampap" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="pwp.exammammogram" name="pwp.exammammogram" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="pwp.womengivenbirth" name="pwp.womengivenbirth" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="pwp.womenmenopause" name="pwp.womenmenopause" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="pwp.womenbreastexam" name="pwp.womenbreastexam" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="pwp.medestrogen" name="pwp.medestrogen" fieldValue="1" cssClass="text large"/>
            </div>
            <div>
                <s:select list="oneToTen" name="pwp.sickdays" label="q36.sickdays" key="q36.sickdays" />
            </div>
        </div>
    </li>
    <li>
        <div>
            <div class="left">
                <fmt:message key="q39.preventiveexam"/>
                <s:checkbox key="pwp.exambowel" name="pwp.exambowel" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="pwp.examdental" name="pwp.examdental" fieldValue="1" cssClass="text large"/>
                <s:checkbox key="pwp.examimmunizationsflu" name="pwp.examimmunizationsflu" fieldValue="1" cssClass="text large"/>
            </div>
            <div>
            </div>
        </div>
    </li>

	<li>
        <div>
            <div class="left">

		    <s:radio key="pwp.fatintake"
		             name="pwp.fatintake"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
		        
            </div>
            <div>
		    <s:radio key="pwp.breads"
		             name="pwp.breads"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
            </div>
        </div>
    </li>
        
	<li>
        <div>
            <div class="left">

		    <s:radio key="pwp.fruitsandvegetables"
		             name="pwp.fruitsandvegetables"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
		        
            </div>
            <div>
		    <s:radio key="pwp.drinksperweek"
		             name="pwp.drinksperweek"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
            </div>
        </div>
    </li>
        
	<li>
        <div>
            <div class="left">

		    <s:radio key="pwp.drugs"
		             name="pwp.drugs"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
		        
            </div>
            <div>
		    <s:radio key="pwp.smokingstatus"
		             name="pwp.smokingstatus"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
        
            </div>
        </div>
    </li>
	<li>
        <div>
            <div class="left">

		    <s:radio key="pwp.chewingtobacco"
		             name="pwp.chewingtobacco"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
		        
            </div>
            <div>
		    <s:radio key="pwp.copingstatus"
		             name="pwp.copingstatus"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
        
            </div>
        </div>
    </li>

	<li>
        <div>
            <div class="left">

		    <s:radio key="pwp.sleep"
		             name="pwp.sleep"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
		        
            </div>
            <div>
		    <s:radio key="pwp.jobsatisfaction"
		             name="pwp.jobsatisfaction"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
            </div>
        </div>
    </li>
        
	<li>
        <div>
            <div class="left">

		    <s:radio key="pwp.seatbelts"
		             name="pwp.seatbelts"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
		        
            </div>
            <div>
		    <s:radio key="pwp.sunprotection"
		             name="pwp.sunprotection"
		             required="true"
		             cssClass="text"
		             listKey ="{'1','2','3','4','5'}"
		             list="{'','','','',''}"             
		            />
            </div>
        </div>
    </li>
        

    <div class="separator"></div>    
    
    <li class="buttonBar bottom">
        <s:submit key="button.save" cssClass="button"/>
        <s:submit key="button.cancel" name="cancel" cssClass="button"/>
    </li>
</s:form>

<script type="text/javascript">
    Form.focusFirstElement(document.forms["wellnessProfileForm"]);
</script>
